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To the Editor: Unlike Yager and colleagues,1 we do not believe that psychiatrists face end-of-life issues with “knee jerk reactions that consider all intentions to end one’s life as irrational and to be stopped at all costs.” Rather, psychiatrists approach the desire to end one’s life from the perspective of venerable, well-reasoned principles of Hippocratic medicine, wrought over two millennia. Similarly, when patients request “assistance” in ending their lives, psychiatrists bring a specialized skill set to bear on the request, independent of any particular DSM diagnosis and without presumption of “mental illness.” Our aim is to help patients mitigate suffering, find some path to a better future, and, ideally, find meaning, even in the face of terminal illness. This approach is no mere reflex; rather, it represents the fundamental ethos of psychiatry, deployed with deep reflection and devotion.

A central question raised by Yager et al1 is whether it is ethical for psychiatrists to be involved in competency assessments in the context of so-called “physician assisted death.” (We endorse, and herein employ, the terminology advocated by the American College of Physicians and the American Medical Association’s Council on Ethical and Judicial Affairs; ie, “physician-assisted suicide” [PAS]).2,3

If, as we believe, PAS is inherently unethical—a position also taken by the World Medical Association4—then it is perforce unethical for psychiatrists to be involved in performing competency assessments on patients requesting PAS. By analogy: the American Psychiatric Association has taken the position that psychiatrists should not perform competency assessments on prisoners slated for execution, though psychiatrists are permitted to relieve the prisoner’s “acute suffering” while he is awaiting execution.5

Again, by analogy, we believe that, where PAS or euthanasia is legal in the United States and internationally, the psychiatrist’s role vis-à-vis patients requesting PAS should be limited to (1) determining if the patient is at immediate risk of self-harm, in which case emergency procedures could be initiated, and (2) alleviating acute suffering, such as panic attacks or extreme emotional distress, using appropriate psychiatric interventions. We also envision the possibility that a connection with a psychiatrist may help the patient work through existential and psychosocial issues that may underlie the wish for death or assisted suicide.

However, in our view, performing a competency assessment entails colluding with a process (PAS) that violates the most basic tenet of Hippocratic medicine—one that has sustained it through two millennia and a multitude of societies that have come and gone, namely, “I will not give a fatal draught to anyone if I am asked, nor will I suggest any such thing.”6